Incision

1. Modified Makuuchi incision is utilized to maximize visibility while lower pain compared to subcostal incision, especially after TAP block (anesthetic/nerve block) along the lateral incision. 
2. Thompson bar or a similar retractor on patient’s right side should have lower bar lowered as much as possible to allow in-line view of vena cava during mobilization portion.
    

Mobilize Liver 

1. Take down the falciform ligament and bilateral coronary/triangular ligaments for optimal mobilization to minimize stress on left liver when retracting the liver. 
2. Retrohepatic vena cava mobilization should take caution to ligate small short retrohepatic vein attachments.
3. Retrohepatic suspensory ligament or Makuuchi ligament is transected to visualize right hepatic vein insertion in order to encircle the vessel.
    

Inflow Control

1. Dissect portal hilum to isolate the right hepatic artery and right portal vein.
2. Be sure to test clamp and confirm blood flow to left liver prior transection.
    

Outflow Control

• Right hepatic vein is encircled and transected with vascular stapler, such as ECHELON FLEX™ Powered Vascular Stapler.
• Important to transect the Makuuchi ligament to visualize the insertion of right hepatic vein.
   

Parenchymal Transection

1. Using an energy device, transect along the line of demarcation of ischemic liver. 
2. Pringle maneuver is utilized during transection – important to have operative team track time on pringle maneuver and allow adequate time to re-pringle. 
3. A combination of bipolar, ultrasonic and mechanical methods utilizing devices such as ENSEAL™ X1 Curved Jaw Tissue Sealer, are used for dissection to transect the liver.
4. Important to coordinate with anesthesia to minimize fluid resuscitation to prevent retrograde flow within liver and minimize hemorrhage. 
5. Frequent use of ultrasound throughout case is critical and must be familiar with ultrasound technique.